This brief describes Medicaid's role for 52 million nonelderly children and adults living in the most rural areas in the United States and discusses how expansions or reductions in Medicaid could affect rural areas. It shows: (1) Rural populations face significant challenges to their health care coverage and access. People who live in the most rural counties of America are spread across almost 2,500 counties that are heavily concentrated in the South and Midwest. Individuals living in rural areas are less likely to be employed and more likely to be low-income than individuals living in other areas. Individuals in rural areas also face significant barriers to accessing care, including provider shortages, recent closures of rural hospitals, and long travel distances to providers. (2) Medicaid plays a central role in helping to fill gaps in private coverage in rural areas. Although private insurance accounts for the largest share of health coverage in rural areas, nonelderly individuals in rural areas are less likely to have private coverage compared to those in urban and other areas (61% vs. 64% and 66%, respectively). Medicaid helps fill this gap in private coverage, covering nearly one in four (24%) nonelderly individuals in rural areas. Further, in many states, Medicaid coverage rates are higher in rural areas than in urban or other areas of the state. In some cases, these differences are large. For example, in California, the Medicaid coverage rate in rural areas is 16 percentage points higher than in urban areas, and Hawaii has a 13 percentage point difference between Medicaid coverage rates in rural and other areas. Similarly, rural areas in Arizona, Arkansas, and Florida have a Medicaid coverage rate that is about ten percentage points higher than the rate in urban or other areas. (3) The Affordable Care Act (ACA) Medicaid expansion led to coverage gains in rural areas. Prior to the ACA Medicaid expansion to low-income adults, rural areas in Medicaid expansion and non-expansion states had similar rates of Medicaid coverage. However, in rural areas that expanded Medicaid, the Medicaid coverage rate increased from 21% to 26% between 2013 and 2015, while it increased by just one percentage point, from 20% to 21%, in rural areas of non-expansion states. As a result, as of 2015, nonelderly individuals in rural areas within non-expansion states were nearly twice as likely to be uninsured as those living in expansion states (15% vs. 9%). Additional action to expand Medicaid within the 19 states that have not yet adopted the Medicaid expansion would likely lead to further increases in coverage among individuals living in rural areas. These non-expansion states are home to 59% of nonelderly uninsured individuals living in rural areas. Conversely, cuts to Medicaid could disproportionately affect people living in rural areas given the large role of the program in these areas.
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